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Should You Give Birth at a Birth Center?

When Gillian Tarr became pregnant with her second child, she chose a free-standing birth center in Seattle for her prenatal care and delivery. Her first baby had been born in a hospital, and while it was a relatively uncomplicated birth, she felt dissatisfied with the care she received.

“It was impersonal and lacked any real support,” said Dr. Tarr, an epidemiologist now living in Calgary, Alberta.

For example, four different obstetricians cared for her during her hospital stay, none of whom she’d met before. During labor, the required fetal monitoring device around her belly often needed adjusting, including in the middle of contractions, and that disrupted her attempts to cope with the pain, as did the strangers regularly coming and going from her room.

Her birth center experience was completely different. “I knew everyone in the room. They were helpful when I needed them and unobtrusive when I didn’t,” she said.

Neither homes nor hospitals, birth centers claim to offer the best of both worlds: midwifery care in a homelike environment, with basic equipment on-site and a plan to transfer to the hospital if necessary.

Nearly 20,000 babies in the United States were born at free-standing birth centers in 2016, an 83 percent increase over the previous decade, based on data from the Centers for Disease Control and Prevention. Not included in those numbers are birth centers located within hospitals, often midwife-led and separate from the main labor and delivery ward.

For women in the United States with low-risk pregnancies, birth centers can offer an alternative to the typically expensive and intervention-heavy maternity care system. Birth centers don’t do cesarean deliveries, but among women in birth center care, about 6 percent of them end up with a C-section after transferring to a hospital; that’s far lower than the 26 percent of low-risk pregnancies over all that are delivered by C-section. Plus, the cost of a birth center delivery is roughly half that of an uncomplicated hospital birth (often paid for by insurers, including Medicaid).


The birth center model of care emphasizes personal attention and familiarity, including longer prenatal visits and continuous support from a midwife through labor. Many also provide home visits and breast-feeding counseling in the postpartum period.

“Creating a place where both the environment and the people are familiar to the laboring woman, I believe, has an impact on their ability to cope in labor,” said Nora Tallman, a certified nurse midwife at the Midwifery Birth Center in Portland, Ore., whose 32-year career has also included home birth and hospital midwifery.

At a birth center, you have “privacy, intimacy, agency and freedom of movement,” said Jennie Joseph, a midwife and owner of a birth center called the Birth Place in Winter Garden, Fla. You won’t be tied to monitoring equipment during labor, and you’re free to eat and drink and have lots of friends and family in the room if you like, all of which may be restricted in a hospital, she said.

Jennie Joseph, owner of the Birth Place in Winter Garden, Fla., and a director at Commonsense Childbirth Incorporated for disadvantaged women, said mothers have “privacy, intimacy, agency and freedom of movement” at birth centers.Credit…Zack Wittman for The New York Times

Good candidates

Birth centers aren’t equipped to handle complicated births or to provide epidural anesthesia. The American Association of Birth Centers says that appropriate low-risk candidates include singleton pregnancies (no twins) that are full term with the baby’s head down (not breech). Mothers should also be free of other medical conditions like insulin-dependent diabetes or high blood pressure. In addition, most birth centers won’t accept women who have previously had a C-section because of the increased risk that the uterine wall might rupture on the cesarean scar, a rare but life-threatening emergency requiring fast access to an operating room.

Birth centers offer lots of other ways of coping with pain besides an epidural, like a warm bath, massageand encouragement from a midwife. Some also offer IV pain medications or nitrous oxide, but the emphasis is on supporting women who want an unmedicated birth.

That was a major reason Breesa Collyer drove two hours from her home in Pleasanton, Calif., to a hospital-affiliated birth center in Davis for both of her sons’ births. “I wanted confidence that everyone around us had the same goals that we did,” she said.

But labor can be long and unpredictably painful. Dr. Steve Calvin, an obstetrician and medical director of the Minnesota Birth Center in Minneapolis and St. Paul, says about one in four to one in five first-time moms at their centers end up transferring to the hospital during labor for an epidural. Both of their centers are close to hospitals — one across the street and the other a mile away.

“It’s not a failure,” Dr. Calvin tells his patients. “You may need an epidural, and that epidural may give you the relief you need to accomplish a vaginal birth.”

Safety concerns

Most births can happen safely outside of a hospital, especially if women have been appropriately screened as low-risk and they’re cared for by experienced midwives. But birth can also take a terrifying turn, for both mother and baby, and if you run into complications in a birth center, you’re farther from the medical resources a hospital can provide.

But for low-risk births, research shows birth centers can be just as safe as hospitals. In England, where midwife-led birth centers are an integrated part of maternity care in the National Health Service, a study of 65,000 births found that those in birth center care were less likely to have a C-section, forceps or vacuum delivery, or episiotomy, and they had no increased risk of mortality or major complication compared to hospital births.

Research from the United States is similarly positive, but it comes with an important caveat. The largest contemporary study was based on data voluntarily submitted by birth centers and represented just 32 percent of birth centers in the United States at the time.

Birth centers “with great outcomes probably are reporting what they’re doing, and then people who don’t have great outcomes or get shut down or run out of money or whatever — we just don’t know what they’re doing,” said Dr. Victoria Woo, an OB-GYN and research fellow at Stanford’s Clinical Excellence Research Center.

Dr. Steve Calvin, an obstetrician and medical director of the Minnesota Birth Center, says about a quarter of first-time moms at their centers end up transferring to the hospital during labor.Credit…Jenn Ackerman for The New York Times

The medical system in the United States — and birth centers’ place in it — is also different from that in Britain. Most birth centers in the United States are privately owned businesses with their own protocols for identifying whether a higher level of care is needed and how the transfer is carried out.

Sometimes birth centers “have a comfortable agreement with the nearby hospitals and midwives have privileges there, and that’s fine,” said Dr. Woo, who has advocated for improved integration of birth centers. “Other times, they have no relationship, and then that often is what leads to bad outcomes, because there will be delays in transfer of care,” she said.

In the United States, about 22 percent of women planning to give birth at a birth center end up transferring to a hospital during labor or soon after giving birth with 2 percent being emergency situations.


Unfortunately, Dr. Tarr was one of these. She unexpectedly hemorrhaged after her daughter was born and had to go by ambulance to a hospital. It was scary, but she got appropriate medical attention in time, and the admitting nurse told her that the midwife had done everything right. Still, Dr. Tarr isn’t sure she would choose a birth center if she had another child. “I am happy with the birth experience I had there, but I am also more scared of what can happen, with no warning, even if you’re low risk.”

Giving birth outside of a hospital doesn’t mean it’s more dangerous, said Dr. Calvin, who specialized in high-risk obstetrics for 25 years before opening a birth center.

Wherever you give birth, your safety depends on what Dr. Calvin calls your “perinatal safety net.” How far are you from an operating room, an anesthesiologist, a blood bank, if something catastrophic happens? Consider that distance in miles, in minutes, and in the vigilance of the people you’ve trusted with your care. Ideally, a birth center should be within 10 to 15 minutes of a hospital, with a well-defined plan for transport, he said.

Dr. Calvin also points out that access to these medical resources is not a given in the United States, even in hospitals. A California study found that just 50 percent of community hospitals had 24-hour anesthesia availability and only 56 percent could perform an emergency C-section within 30 minutes.

“The ideal is to have support for natural birth and a robust safety net that finds the sweet spot between obstetric care that is ‘too much, too soon’ and ‘too little, too late,’” Dr. Calvin said.

What to Ask When Considering a Birth Center

Mary-Signe Chojnacki, clinical director at the Minnesota Birth Center, attends to Kait Baudette, 41 weeks pregnant.Credit…Jenn Ackerman for The New York Times

If you’re considering a birth center, start by asking about licensing and accreditation. Most states license birth centers as health care facilities, but some have stricter requirements than others, and nine states don’t license or regulate birth centers at all.

Birth centers can also apply for accreditation from the Commission for the Accreditation of Birth Centers, which relies on national quality standards. However, only about a third of birth centers are currently accredited.

If a birth center isn’t licensed and accredited, ask why it isn’t, and know that this means there’s less scrutiny and oversight for its practices.

You should also ask about the center’s criteria for accepting patients. “If they’re willing to take anybody, that’s asking for trouble,” Dr. Calvin said. His center has a published list of criteria.

Ask about the plan for transfer, including what your midwife’s role will be if you go to a hospital. Certified nurse midwives can have hospital privileges so may still be able to continue to care for you in the hospital, whereas certified professional midwives do not. Yours may be able to stay with you, but not as a health care provider.

Visit the birth center, take a tour, ask lots of questions, and see how it feels. “Do you have that sense of comfort?” Ms. Joseph asked. “If you walk in the door and you don’t feel right, then that’s not you. That’s not your birth center.”

Alice Callahan, a writer in Eugene, Ore., is the author of “The Science of Mom: A Research-Based Guide to Your Baby’s First Year.”

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